Insurance Follow-Up Specialist

Location: 30 Old Rudnick Ln

Status: Full Time 80 Hours

Shift: Days

Salary Range: 19.18 - 28.77 HOURLY

• Generous Paid Time Off and Paid Holidays
• Matching 401(k)/403(b) Plans
• Excellent Health, Dental, and Vision
• Disability and Life Insurance options
• On Site Child Care
• Educational Reimbursement
• Health Care and Dependent Care Flex Spending Accounts
• Voluntary Benefits to include Critical Care Coverage and more!

The Insurance Follow-Up and Collections Specialist is responsible for following up on all hospital and/or professional insurance claims. The position requires advanced knowledge of all payers and claim types, and the ability to prioritize workflow to meet insurance company filing deadlines for claim submission, claim reconsiderations, and appeals, and achieve targeted receivables monthly, and expedite cash flow. Specific duties involve researching unpaid claims, responding to insurance company information requests, submitting reconsiderations for partially paid claims, interpreting payer denials and reviewing medical records as appropriate, appealing denied claims and resolving payment variances as encountered to facilitate timely patient billing.

As needed, the Specialist will make accurate recommendations for system or process changes to mitigate denials. The Specialist also serves as a subject matter expert for colleagues concerning expected reimbursement, denials, and other insurance company contract requirements and/or conflicts.

• Follow up on unpaid claims and appeals via telephone or web-based claim inquiries. Complete imaging system correspondence work queue(s) as appropriate. Identify and perform appropriate contract and/or other denial related write offs. Research missing payments via undistributed work queues and apply the payment to the correct invoice. Document accounts thoroughly with all information concerning claim and expected payment status and necessary follow up action taken to secure payment.
• Verify insurance eligibility, correct claim errors, submit claim reconsiderations, write appeals, and provide requested information to resolve denied claims. Interact with various long term care offices to correct denials as appropriate.
• Interpret payer denials, review submitted claim information, and medical records to understand the denial. Refer denied claims to correct department work queue with coding recommendations or other clarification questions as needed to resolve the denial; resubmit denied claims with revised information. Refer patients for Financial Assistance based on Medicare/Medicaid benefits exhausted and delayed lower level of care placement scenarios.
• Convert denied inpatient admissions to observation claims based on the insurance company approving observation.
• Contact patients to resolve insurance company-initiated information requests as needed to facilitate claim payment.
• Review and interpret Federal and State regulations for Medicare and Medicaid and contract terms for Managed Care, Commercial, and Workers Compensation as applicable.
• Understand Bayhealth’s contracted reimbursement rates. Review insurance company payment variances and, as needed, calculate expected reimbursement for outlier claims and claims with days denied as not medically necessary. Pursue underpaid claims and submit over payments for refunds. Document inappropriate denial and payment variances on spreadsheets, participate in calls with insurance company provider representatives, and accurately communicate variance reasons and expected resolution.
• Process credit balances; submit over payments electronically to insurance companies who require electronic submission to correct the over payment. As applicable, review the third‑party vendor submitted refunds for accuracy.
• Escalate insurance company and internal claim related issues to management as appropriate for resolution.
• Serve as a subject matter expert for colleagues internal and external to PFS. Accurately research payer issues and provide payer/plan specific education on billing and/or claim requirements. Ensure requests for system and process changes are thoroughly examined before making management recommendations.
• Perfor…